key: cord-1018761-u19xsx2e
authors: Cabal-Herrera, Ana Maria; Mateen, Farrah J.
title: COVID-19 in a patient treated with eculizumab for aquaporin-4 neuromyelitis optica
date: 2021-04-27
journal: J Neurol
DOI: 10.1007/s00415-021-10578-7
sha: ff4036ce81347ea8a7e44108da63d11c7a6dea42
doc_id: 1018761
cord_uid: u19xsx2e

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she presented with shortness of breath, headache, fever, and cough. These symptoms resolved after 3 days. She had a positive nasopharyngeal swab test for SARS-CoV-2 infection by reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay, 10 days after her eculizumab infusion. She did not receive any specific therapy or oxygen for COVID-19 but she self-dosed her steroids, taking 20 mg daily once then 10 mg daily afterwards. 3 weeks later, she emergently presented for chest pain and palpitations. On physical examination, she had normal vital signs and her laboratory tests were reassuring: serum d-dimer was negative and her troponin levels were normal. Follow-up has been uneventful at 8 weeks. She continued steroids (7.5 mg daily), and received eculizumab 900 mg IV 3 and 7 weeks after her COVID-19 diagnosis. Serum COVID-19 nucleocapsid antibody was positive 49 days after her first COVID-19 symptoms.

We present a patient with PCR-confirmed, symptomatic COVID-19 while treated with eculizumab for NMO, highlighting her overall favorable outcome. There are reports of patients with other autoimmune diseases on chronic treatment with eculizumab presenting with confirmed confirmed SARS-CoV-2 infection [1] [2] [3] [4] [5] [6] (Table 1) ; most had a mild disease course without recognized sequelae. It is possible that eculizumab renders people susceptible to SARS-CoV-2 infection; however, a protective effect against the development of severe COVID-19 disease may also occur [7-9]. Although eculizumab has been given safely during COVID-19, a survey of 192 neurologists from the United States and Canada in April 2020 found that many felt eculizumab could put their patients at risk for COVID-19 [10].

There is no consensus on the safe administration of eculizumab in the context of COVID-19, although recommendations exist [11] . Extrapolating from other autoimmune diseases treated chronically with eculizumab, there is no evidence to prompt its suspension in the context of a SARS-CoV-2 infection [12] . Considering the debilitating and severe nature of NMO, it is important to balance the benefits of preventing a relapse with the potential risk of rendering a patient more susceptible to SARS-CoV-2 infection.

We also demonstrate that antibody formation to SARS-CoV-2 occurs following PCR-confirmed COVID-19 in a patient treated with eculizumab, implying immunity to SARS-CoV-2 could occur during ongoing complement inhibitor therapy. Despite ongoing treatment with eculizumab, this patient's immune system was able to mount an antibody response to COVID-19. Antibody formation implies an immunogenic vaccine response in eculizumabtreated patients will likely occur. Meanwhile, we recommend that patients with NMO continue adopting all preventive measures against COVID-19, including vaccination, and those on eculizumab treatment should not suspend or discontinue it if exposed to SARS-CoV-2. Recovered [1] Funding The authors received no financial support for the research, authorship, and/or publication of this article.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Recovered [3] 

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